The 7-year-old girl had obvious internal injuries. Her upper abdomen had been crushed at the moment of impact and she was at risk of bleeding to death. A small crowd had gathered at the car accident scene off Ellerslie Road in south Edmonton, gawking as the lone paramedic, a first responder, pulled up in an SUV.
Minutes ticked by. With no ambulance to transport the girl to hospital, the paramedic knelt beside her on the grassy median, comforting her as best he could while they waited. One minute, two minutes, stretching into 40 minutes, until finally the wail of a siren.
“I think the most important point for the public to understand is that our system is in shambles,” said an Edmonton paramedic with decades of experience. “Calling 911 is not reliable. The system’s ability to respond to your emergency is a roulette wheel.”
In our recent interviews with one dispatcher and 19 paramedics from across the province, a common theme emerged: when Albertans call 911 and request an ambulance, whether or not they receive a timely response increasingly comes down to luck.
Paramedics consistently described an Emergency Medical Services (EMS) system so dysfunctional and routinely overwhelmed it compromises their ability to provide even adequate, let alone life-saving, care. More than a dozen paramedics could readily recall incidents—in a profession where “time is tissue”—of excessive response times.
One told us he arrived at the scene of an ultimately fatal cardiac arrest 35 minutes after the call came in. Another drove past three empty ambulance stations to reach a patient, now unresponsive, and immediately started chest compressions. One is haunted by the memory of a father who had watched his seizing child convulse for 45 minutes before help arrived.
A veteran paramedic joked darkly that they don’t get a chance to develop PTSD anymore “because by the time we get to the calls that would normally cause a stress reaction, the patient is already so far gone that we’re not fighting for them. We’re just, like, ‘Oh, there’s a body’ or ‘Oh, there’s nothing we can do.’ Where it used to be we would get there in time.”
Most talked about a workplace in such shambles that it psychologically damages them. Many are counting the days until they can escape.
They spoke on a confidential basis, fearful of reprisal for voicing concerns about a system many of them no longer trust to serve the public, including their own loved ones. “If something happened in my family, I would probably phone dispatch and be, like, ‘I’m a paramedic, tell me where the truck is, now,’ ” a central Alberta paramedic said. “Because I’m going to need to know if I’m throwing my family in the car or not. Whereas, you know, 10 years ago, I would not do that.”
“The system is in shambles. Our ability to respond to your emergency is a roulette wheel.” —Edmonton paramedic
In 2004 Alberta’s health ministry assumed control of the province’s EMS system, and in 2009 it transferred its management to the newly created Alberta Health Services. Critically, AHS instituted major reforms that created a “borderless” system, in which ambulances no longer serve a specific area but can be dispatched into neighbouring jurisdictions. The main rationale was to ensure the closest ambulance responds to serious calls.
Backlash followed AHS’s centralization of most EMS services in Alberta: “The main concerns and criticisms brought forward by some EMS stakeholders and municipalities were that the evolving ‘borderless’ provincial ambulance system was leaving some communities with insufficient ambulance coverage and that some ambulances were tied up with long wait times at emergency departments in urban hospitals,” a Health Quality Council of Alberta report stated. AHS completed centralization by taking over services from Calgary, Lethbridge, Red Deer and Wood Buffalo in 2020.
Paramedics now say that, as call volumes have increased without staffing keeping pace, the borderless system has evolved into a backstop in which ambulances from rural Alberta are routinely pulled into urban areas, sometimes leaving their communities without coverage.
Sometimes the pull into urban areas is gradual, a “stairstep” into city limits: the ambulance will be dispatched to a call close to a city, then “stood down” because a closer ambulance is assigned. But before they can return to their community, they are tagged on another city call. At a certain point they are inevitably the closest available ambulance for city emergencies and are assigned call after call.
One rural paramedic likened it to the pull of a “black hole.” “You’re trying to use all of your energy to get away,” he said. Recently, when supervisors took his truck out of service so he and his partner could take their break, they instead drove as fast as they could away from the city, “far enough that there may be another truck closer than [us] when a call comes in.”
Several paramedics said it’s difficult some days to take a break, even to go to the bathroom. One rural paramedic described return trips from Calgary where he and his partner were so exhausted that it was no longer safe, and they had to pull over and sleep for 45 minutes.
But it’s not as though more ambulances is the answer. When AHS announces new ambulances, as it did last September, it omits the fact that the health authority struggles to staff the ambulances it already has. During one shift last summer, a long-time EMS dispatcher recalled that “94 trucks were down. That’s 20 per cent of [our] workforce.”
An Edmonton paramedic has been tracking ambulance staffing numbers. For the first 10 months of 2022, he says, 20–30 per cent of the city’s ambulances regularly were off the road because they were unstaffed. If these numbers reflect the daily reality, that means fewer crews are responding to ever-increasing call volumes. AHS says the number of 911 calls in Alberta has grown 30 per cent since 2018–2019.
The province blames the rising number of calls largely on the COVID-19 pandemic. But while paramedics acknowledge call volumes exploded at times during the pandemic, they maintain the system has been in crisis for years. “COVID isn’t the reason for this collapse,” an Edmonton-area paramedic said. “This collapse was coming.”
A paramedic who works solo in an SUV called a Paramedic Response Unit (PRU) said his record for responding to calls in Edmonton is 33 calls in a 12-hour shift. Another PRU paramedic based in the city’s deep south said it’s now common to be dispatched to downtown or northside calls—or even to Strathcona County, the municipality east of Edmonton.
“You’re always on a cortisol rush,” said a rural paramedic from central Alberta, “because you’re, like, go go go non-stop. And then you start to live in that high adrenaline, cortisol. Always anger, fear, flight; that’s just physiology, right? And then you’re not you when you come home.”
The EMS dispatcher said call volumes have increased so dramatically over the past three years that sometimes, if she and her colleagues aren’t providing urgent advice such as how to perform CPR, they tell the caller they have to hang up to respond to unanswered 911 calls. This is known as an “urgent disconnect.”
“That’s hard to do,” she said. “That might be a call I would normally stay on the line for, and now I can’t. The next 911 might be a cardiac arrest, right? I don’t know, but I need to disconnect because the phone lines are ringing off the hook. And no one else in the province is available to take a 911 [call].”
Sometimes, she said, dispatchers have to call back scared and anxious people and explain they don’t have an ambulance to send yet. “It’s discouraging. Sometimes you go home and think, ‘Did I do any good today at all? I couldn’t get people the help they needed.’”
Red alerts−when no ambulances are available−have become the norm.
The dispatcher is describing a phenomenon that has entered the public lexicon—a red alert, when no ambulances are available to respond to 911 calls. All 20 frontline EMS staff we spoke to said red alerts have become the norm rather than the exception.
Red alerts should only occur during a mass casualty event, a Calgary paramedic said. “[But] here, by the time it gets two hours into a shift, we’ve already drained all our surrounding resources in the city,” he said. “So if anything were to happen, there is no one to go.
“It has gotten to the point where… it’s not hoped for, but it is stated frequently in the hallways, ‘Well, maybe somebody ‘important’ will die because of this, and maybe then something will change.’ ”
The same paramedic said they have become desensitized to red alerts. “It used to be a supervisor would come into the ambulance bay at a hospital and be, like, ‘Hey, guys, we’re in red alert.’ And you would see all the crews scrambling,” he said. Now, “we just turn to him and it’s, like, ‘Yeah? No shit,’ ” he said. “But I’m going to finish my coffee and finish my paperwork because we’re always in a red alert, so what difference does my clearing immediately make?’”
The dispatcher said it is now common to have “15 [to] 18 calls pending. So we have them in our computer, but we have not dispatched any ambulances to those calls.
“And there may be calls that have been sitting there for six, seven hours,” she added.
Calls are labelled based on their level of urgency. Dispatchers code calls from A (Alpha, the least serious) to E (Echo), with subcategories denoting the degree of seriousness. A minor fall might be an Alpha while a cardiac arrest would be an Echo.
Even when paramedics respond to more-serious calls in time, patients may not quickly get the care they need.
An Edmonton PRU paramedic recently responded in his SUV to a call just west of downtown. The man’s heart was failing and his lungs were filling with fluid. “I was treating him for his heart failure on the front steps of his apartment, waiting for a transport truck to come from Sherwood Park,” the paramedic said.
“I’m five minutes away from the Alex,” he said, referring to a downtown hospital. “But here I am spending half an hour on scene, trying to stabilize this guy, trying to get the fluid out of this guy’s lungs while his heart fails, waiting for an [ambulance].” He doesn’t know if the patient survived.
Paramedics refer to PRUs as “clock-stoppers,” designed to arrive quickly to serious calls. They make AHS response times look better, but the reality for the patient is that often they’re stranded, waiting for an ambulance to transport them to hospital.
A glaring, inexplicable disparity exists between what paramedics say are consistently excessive response times and what AHS says its statistics show. The use of PRUs might explain some of the gap. Urban paramedics can attend six to 10 calls in a shift, while PRUs race to a dozen or more, skewing the response-time statistics with each stopped clock.
The AHS goal is for paramedics to respond to at least half of life-threatening city calls within eight minutes, and 90 per cent within 12 minutes. In smaller communities with populations of more than 3,000, that latter figure is 15 minutes, with lengthier benchmarks for more rural and remote areas.
Alberta Health Services declined an interview request. In a statement, spokesperson Kerry Williamson said EMS median response times “continue to be lower than or close to targets, particularly for rural and remote communities,” despite the 30 per cent increase in call volume.
In Edmonton, EMS meets its response target of eight minutes or less for at least half of the calls, he said, but that is not yet the case in Calgary.
Williamson also said the number of suburban and rural ambulances migrating into metro areas has significantly decreased. That could simply mean the ambulances are staying in the metro area, an issue flagged by rural paramedics and one of many AHS did not address.
The AHS statement touted an additional $64-million in funding to EMS in the provincial government’s 2022 budget, roughly a third of which was used to buy 19 new ambulances and add more hours of EMS coverage.
Two Calgary-area paramedics said staff have been told to park their old ambulance at a station and take out a new one. “So on paper, we can say every day the new ambulances were staffed, but they’re actively dropping the truck that I was scheduled on off the board,” one of them said.
Ambulances outside the emergency department at Edmonton’s Walter C. Mackenzie Health Sciences Centre. Photo: Alamy.
Paramedics and AHS disagree on how long it is taking to reach patients. There is no disagreement, however, that once at the hospital paramedics encounter a systemic bottleneck that chronically keeps them off the road for hours, sometimes entire shifts.
Many patients can’t be left unattended, but there are no available beds and no nurses to care for them. Paramedics park patients in a hallway and then essentially function as nurses, feeding them, helping them in the toilet, even taking them for tests.
Often there are so many paramedics waiting in hospitals that they cover for each other. “We will trade off and be, like, ‘Hey, I’ll take yours and yours, so you two can get back out. And then at your end of shift, you come back and try to take my patient,’ ” one paramedic said.
Several described clocking in and driving straight to the hospital. “I spend my whole 12 hours there,” a Calgary paramedic said. “And then I go ‘I didn’t respond to one call in a day.’ ”
There have been times when paramedics transfer care of a patient to a colleague in the morning, and “when the night crew comes back on, they are handing that patient back… people are waiting in the hallway that long, and waiting in the ER that long, for a bed.”
But sometimes when there’s a red alert and 911 calls are mounting, much like the dispatchers’ “urgent disconnect,” paramedics have to abandon their hallway patients. In fact, there is a policy that prescribes it.
A long-time Edmonton paramedic said that up until the last few years he had never even heard of this “mandatory offload” policy. “It didn’t happen for years,” he said. “All of a sudden, it was happening almost daily.” Patients, some in a terrible condition, are simply abandoned in an ER hallway, because some other Albertan, somewhere else, needs help even more urgently.
Many paramedics tempered or qualified their descriptions of how chaotic the system is and how it has affected them, because they appeared to fear being accused of hyperbole. Some simply seemed tired of talking about the “bad calls,” the incidents they may never forget. The “bad call” stories were legion, including many about patients who might have survived but didn’t.
A paramedic based in a northern Alberta town told of being called to a business for a cardiac arrest. “The vast majority of cardiac arrests don’t [survive],” he said. “If there was one to be saved, I would say it would have been this one. The stars kind of aligned for it.”
When the 911 call came in, the ambulance was nearby and the paramedics were at the patient’s side within three or four minutes. By pure luck, an off-duty nurse had immediately begun chest compressions.
But he and his partner were both primary care paramedics and couldn’t administer epinephrine, a drug used to kick-start the heart. The community’s two advanced-care paramedics were on a low-priority transfer in another town. (Transfers are common in rural communities; ambulances take patients to larger facilities that have specialists, diagnostic tools such as MRIs/CT scanners, etc.) “We waited for well over half an hour for advanced life support to show up,” he said. The patient died while they waited.
Two weeks later, the young paramedic had his first panic attack.
Several paramedics told of driving across a city, or into the city from a rural community—up to an hour and a half—to reach an emergency call such as a cardiac arrest.
These sorts of system failures are known by EMS management. There is a voluntary reporting protocol, a Reporting and Learning System (RLS) online form that paramedics are encouraged to file when a system failure occurs.
Most paramedics said the RLS is useless because management gives no indication their reports are acted on. A Calgary-area paramedic said he has filed hundreds of RLS forms. “It doesn’t seem to change,” he said. “Occasionally you get a phone call from your supervisor saying things like, ‘Well, that’s just how the system is,’ when the whole point of those reports is to try to change the system.”
Several told us they were directed to stop filing RLS forms. In nearly every interview, paramedics said EMS managers don’t listen to frontline staff.
Compounding their frustration is that some systemic fixes are obvious: don’t use scarce ambulance resources to transport patients to appointments or tests unless absolutely necessary; expand access to mental health supports and family doctors to relieve the emergency room bottleneck; educate the public about when it’s appropriate to call an ambulance.
A rural paramedic working outside Edmonton told us, “Albertans need to stop calling 911 for unnecessary calls…. There needs to be an educational piece.” Another estimated that maybe one-fifth of his calls don’t actually require EMS. But many paramedics told us people often aren’t in a great position to judge whether they or a loved one truly need an ambulance, so, when in doubt, they should call.
Others pointed out that Albertans don’t always have an option. One Edmonton paramedic said lack of access to after-hours care puts stress on EMS: “Another factor is no access to urgent care centres…. You know, you cut your hand in the middle of the night—medicentres, they don’t even take walk-ins anymore, it’s mostly just by appointments. So you have to go to a hospital for those minor things, right?”
Paramedics say call volumes have increased without staffing keeping pace.
Many added that a big part of the solution is not only for AHS to hire more paramedics but also to create a culture that will retain staff. Ambulances are regularly unstaffed because paramedics call in sick, are off on stress leave or have abruptly quit the profession. Most of the paramedics we interviewed talked about a culture that wasn’t based on mutual respect or trust with management and was at times confrontational. Some called it toxic and said workers who speak up are disciplined.
In a departure from the rote AHS talking points, the government of Premier Danielle Smith in late 2022 acknowledged Albertans are waiting too long for ambulances. In a November news release, it announced new AHS administrator Dr. John Cowell will work to improve EMS service, including by reducing the time paramedics spend at hospitals and allowing them to decide whether a patient needs to be transferred by ambulance to the emergency room.
Those changes, if implemented, may come too late for some paramedics. Strikingly, many of the paramedics we interviewed said they’re already searching for another job—“Everybody’s looking for a way to get out,” one rural paramedic said of his colleagues. Others doubt they’ll make it more than a few years in their current positions.
The overwhelming picture that emerged is of people who entered the profession out of a desire to help others, only to be ground down by a system so dysfunctional, so demoralizing, that many struggle every day to muster the will to continue.
A paramedic with more than two decades’ experience described how he sits on the edge of the bed before the beginning of another stretch of shifts, debating whether to call in sick. “You just kind of take a minute, and always the thought is, ‘It’s quarter after four in the morning and this has got to be my life again for the next 96 hours. Have I got the gas in the tank to do four days of this or not?’ ”
Still, at least for now, many are dedicated to the profession. They continue to file the RLS reports in the hope of changing the system, and they continue to work the long hours and the forced overtime.
“I’m a fixer, I guess,” a rural paramedic told us, explaining why he’s been providing information about substandard service for the union’s social media. “The public is unaware,” he said, his voice quavering with emotion. “They don’t know how bad it is until it’s too late, until they call for help and no one comes.”
Jennie Russell and Charles Rusnell are Edmonton-based investigative reporters who for the past decade have specialized in political accountability journalism.
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